Background:
Health disparities in childhood immunization persist across the United States, with children from low-socioeconomic status (SES) households often experiencing lower vaccination coverage compared to their higher-income peers. Poverty, lack of health insurance, transportation difficulties, and missed work for parents are all barriers that negatively affect children and their families from accessing routine childhood immunizations. While the federally funded Vaccines for Children (VFC) program provides no-cost vaccines to eligible children, obtaining access to a health care provider utilizing the VFC program can limit its impact (Valier et al., 2024).
In Pennsylvania, the School Code sets out specific immunization requirements for attendance in school. Students who do not meet the age-appropriate immunization requirements can be excluded from school starting on the 5th day of the new school year, or they may not be able to start school at all, until such time as they meet those requirements.
Utilizing the NASN School Nursing Practice Framework, the role of the school nurse is to monitor immunization compliance and to collaborate and connect students and families with available resources. Additionally, a school nurse needs to advocate for programs and services that promote health and provide equitable access to health care. (NASN, 2024)
School-based vaccination programs (SBVPs) offer a promising strategy to overcome these barriers by providing accessible vaccination services directly within the community.
Methods:
This study evaluates the data collected over eight years from a school-based VFC immunization program operated by the Reading School District.
The Reading School District, which is in Reading, Pennsylvania, has an enrollment of approximately 19,000 students in twenty-four district school buildings. The student population is 87% Hispanic, 5-6% Black, and 5% White, with universal free meals provided to all students. Based on the social determinants of health (SDOH), as defined by the CDC Healthy People 2030, the students and families living in the Reading School District face many risk factors that impact their ability to access medical care, including routine childhood immunizations.
The Reading School District VFC Program is in place to remove the barriers preventing students, who are uninsured or have Medicaid, from receiving the school mandated vaccines. The parents/guardians of students who do not meet the school mandated vaccine requirements, and who meet the eligibility requirements for the VFC Program, are provided with an opportunity to schedule an appointment at the school clinic by the building nurse, thereby facilitating students’ ability to return to or continue attendance in school.
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The VFC program is fully operated and staffed by the school district nurses. The clinic, which is located in the high school health room, is managed by a district nurse, who is the designated VFC Coordinator and primary clinician for the two weekly clinics.
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The district has increased the number of available appointments over the past eight years in response to the increasing needs of the community. The clinic started with one clinic and ten appointments a week, to now two clinics a week with approximately 25-30 available appointments. Additionally, every August and September, there are six large vaccine clinics held, each staffed by 8-12 district nurses. This has resulted in an additional 250-300 students receiving vaccines each school year.
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All written materials are provided in multiple languages, i.e. English, Spanish and Haitian Creole.
Primary outcomes hoped to show a significant decrease in the number of students excluded from school due to missing mandated vaccines. We compared immunization exclusion rates, starting with the 2017-18 school year through the 2024-25 school year, and the impact of the school district VFC program on these rates.
Results:
The data, collected over the past 8 years of operating the vaccine program, clearly demonstrates that the school-based VFC program resulted in an eighty-seven percent decrease in the number of students who were excluded from school due to incomplete/ missing required immunizations.
Conclusion:
Immunization inequity, due to low-SES and other health disparity issues, is a serious concern for the students, families and communities. School nurses are often a trusted presence in the community, giving them a unique opportunity to build relationships with students and families. The Reading School District school nurses have made great strides in increasing access to routine immunizations. With high immunization rates, the district dramatically reduced the number of students excluded from school for missing mandated vaccines. This, in turn, removes a major barrier to education for these students, improving their academic outcomes.
Implications for practice:
A school-based VFC vaccination program has the potential to be a highly effective and equitable strategy for delivering immunizations to underserved low-SES populations. By leveraging the school setting, this model can overcome many access barriers and promote public health equity by ensuring students can receive lifesaving, routine vaccinations, regardless of their family's income, lack of insurance, ethnicity, or other disparities.
References
National Association of School Nurses (2024). A contemporary frameworkupdate for today's school nursing landscape: Introducing the school nursing practice framework. NASN School Nurse, 39(3), 140-147. https://doi.org/10.1177/1942602X241241092
Office of Disease Preventation and Health Promotion. (n.d.). Healthy People 2030. Washington: United States Department of Health and Human Services. Retrieved from https://health.gov/healthypeople
Valier, M.R., Yankey, D., Elam-Evans, L.D., Chen, M., Hill, H.A., Mu, Y., Pingali, C., Gomez, J.A., Arthur, B.C., Surtees, T., Graitcer, S.B., Dowling, N.F., Stokley, S., Peacock, G., Singleton, J.A. (2024). Vital signs: Trends and disparities in childhood vaccination coverage by vaccines for children program eligibility- National Immunization survey-child, United States, 2012-2022. Morbidity and Mortality Weekly Report, 73(33), 722-730. https://doi.org/10.15585/mmwr.mm7333e1